DX-1303 Form
2008-D2-19-AttA.doc
2010 Census Coverage Measurement Initial Housing Unit Followup
DX-1303 Form
OMB: 0607-0956
Form DX-1303 OMB No. XXXX-XXXX EXPIRES: XX/XX/20XX <LCO #>.<CLUSTER#> PAGE: 2 of 4
[Put Barcode here ]
FORM DX-1303 (09/11/2007) U.S. DEPARTMENT OF COMMERCE
OMB No. XXXX-XXXX: Economics and Statistics Administration
Approval Expires XX/XX/20XX U.S. CENSUS BUREAU
Census Coverage Measurement (CCM)
Initial Housing Unit Followup (IHUFU) Packet Cover Page
2008 Census Dress Rehearsal
A. Cluster Identification B. Followup Units in Packet
1. Cluster No.
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2. LCO name
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3. Code |
4. County
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5. Code |
6. State
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7. Code
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8. TEA
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Block Number |
Number of Followup Units per Block |
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Total Number of Followup Units______ |
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C. Field Staff Identification
Position
(a) |
Name
(b) |
Applicant ID
(c) |
Dates |
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Assigned (e) |
Completed (f) |
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Month |
Day |
Month |
Day |
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1. Crew leader |
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2. Interviewer |
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3. Interviewer |
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CENSUS CONFIDENTIAL: RESTRICTED DATA FOR OFFICIAL USE ONLY. Information contained in this report is for use by the Census Bureau and is confidential by law (Title 13, U.S.C.). It may be seen only by sworn Census employees and may be used only for statistical purposes.
NOTICE TO FINDER: If found, please either call 1-301-763-3301 to arrange for pickup OR mail to: Census Coverage Measurement, U.S. Census Bureau, 4600 Silver Hill Road, Washington, DC 20277-6081, Attn: CCM Field Staff
Locating Instructions
If you cannot locate the address, or have trouble determining whether it is the same as another address on your list:
1. Look within and outside the cluster
2. Approach a householder, apartment/building manager, neighbor, postal worker/letter carrier, etc., and use this introduction as a guide:
Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking addresses in this area as part of the 2008 Census Dress Rehearsal. Here is some information about what we are doing. The questions should only take 3 minutes. (Hand the respondent a Privacy Act Notice and allow time for him or her to read it.)
3. Ask the following questions as needed:
3a. Was (street name) ever known by another name?
3b. Did or does the house/apartment at (address) ever use a different address?
3c. Is (address) ever identified in any other way?
CCM Nonmatched Address (NI)
CCM Address |
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Census Address |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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CCM ADDRESS |
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1. Is there a housing unit at CCM ADDRESS? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): _____________________________________________________________
No Please describe the status of CCM ADDRESS. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: _________________________________________________
Describe facility: ___________________________________________________
___________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
________________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_____________________________________________________________________________________
__________________________________________________________________ Skip to Question 6
2. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS
Yes
No In what block number is CCM ADDRESS? (B1)
3. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?
Yes Enter Census ID:
No
CCM Nonmatched Address (NI)
CCM Address |
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Census Address |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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CCM ADDRESS |
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4. Look at the CCM column of the Housing Unit Reference List. Notice that the address in the CCM address box at the (F1)
top of this form is already listed in that column. Aside from that address, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS?
Yes Enter CCM MSN and WMSN
No
5. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
6. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
7. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Census Nonmatched Address (NE)
CCM Address |
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Census Address |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
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XXXXX |
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CENSUS ADDRESS |
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1. Is there a housing unit at CENSUS ADDRESS? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): _____________________________________________________________
No Please describe the status of CENSUS ADDRESS. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: _________________________________________________
Describe facility: ___________________________________________________
___________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
________________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
____________________________________________________________________________________
__________________________________________________________________ Skip to Question 6
2. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS
Yes
No In what block number is CENSUS ADDRESS? (B1)
3. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)
housing unit as CENSUS ADDRESS?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
Census Nonmatched Address (NE)
CCM Address |
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Census Address |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
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XXXXX |
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CENSUS ADDRESS |
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4. Look at the Census column of the Housing Unit Reference List. Notice that the address in the Census address box at (G1)
the top of this form is already listed in that column. Aside from that address, do any other addresses in that column
refer to the same housing unit as CENSUS ADDRESS?
Yes Enter Census ID:
No
5. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
6. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
7. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Possible CCM-Census Match (P)
CCM Address |
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Census Address |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS |
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CENSUS ADDRESS |
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[See LOCATING INSTRUCTIONS on the Cover Page if you are having trouble determining whether one address is the same as another.]
1. Do the following addresses refer to the same housing unit? (C)
CCM Address: CCM ADDRESS
Census Address: CENSUS ADDRESS
Yes What is the correct address? (C1)
CCM ADDRESS
CENSUS ADDRESS
Other _________________________________________________
What is the correct block? (C2)
XXXXX Skip to Question 11
Other _________________________________________________ Skip to Question 11
No
CCM ADDRESS
2. Is there a housing unit at CCM ADDRESS? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 12
Possible CCM-Census Match (P)
CCM Address |
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Census Address |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS |
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CENSUS ADDRESS |
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3. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS
Yes
No In what block number is CCM ADDRESS? (B1)
4. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?
Yes Enter Census ID:
No
5. Look at the CCM column of the Housing Unit Reference List. Notice that the address in the CCM address box (F1)
at the top of this form is already listed in that column. Aside from that address, do any other addresses in that
column refer to the same housing unit as CCM ADDRESS ?
Yes Enter CCM MSN and WMSN
No
6. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
Possible CCM-Census Match (P)
CCM Address |
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Census Address |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS |
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CENSUS ADDRESS |
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CENSUS ADDRESS
7. Is there a housing unit at CENSUS ADDRESS? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No Please describe the status of CENSUS ADDRESS. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 12
8. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS
Yes
No In what block number is CENSUS ADDRESS? (B1)
9. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)
housing unit as CENSUS ADDRESS?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
Possible CCM-Census Match (P)
CCM Address |
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Census Address |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS |
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CENSUS ADDRESS |
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Look at the Census column of the Housing Unit Reference List. Notice that the address in the Census address box (G1)
at the top of this form is already listed in that column. Aside from that address, do any other addresses in that
column refer to the same housing unit as CENSUS ADDRESS?
Yes Enter Census ID:
No
11. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
12. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
13. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CCM-Census Match/Duplicate CCM Address (M/DI)
CCM Address(es) |
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Census Address(es) |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS 1 |
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CENSUS ADDRESS |
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XXXXX |
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CCM ADDRESS 2 |
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[See LOCATING INSTRUCTIONS on the Cover Page if you are having trouble determining whether one address is the same as another address.]
1. Do the following addresses refer to the same housing unit? (C)
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes What is the correct address? (C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 6
Other _________________________________________________ ® Skip to Question 6
No
CCM-Census Match/Duplicate CCM Address (M/DI)
CCM Address(es) |
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Census Address(es) |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS 1 |
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CENSUS ADDRESS |
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XXXXX |
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CCM ADDRESS 2 |
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2. Is there a housing unit at CCM ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 2. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
__________________________________________________________________ Skip to Question 7
3. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 2
Yes
No In what block number is CCM ADDRESS 2? (B1)
4. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?
Yes Enter Census ID:
No
CCM-Census Match/Duplicate CCM Address (M/DI)
CCM Address(es) |
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Census Address(es) |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS 1 |
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CENSUS ADDRESS |
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XXXXX |
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CCM ADDRESS 2 |
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5. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes Enter CCM MSN and WMSN
No
6. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
7. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
8. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CCM-Census Match/Duplicate Census Address (M/DE)
CCM Address(es) |
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Census Address(es) |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS |
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CENSUS ADDRESS 1 |
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XXXXX |
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CENSUS ADDRESS 2 |
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[See LOCATING INSTRUCTIONS on the Cover Page if you are having trouble determining whether one address is the same as
another address.]
1. Do the following addresses refer to the same housing unit? (C)
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes What is the correct address? (C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 6
Other _________________________________________________ ® Skip to Question 6
No
CCM-Census Match/Duplicate Census Address (M/DE)
CCM Address(es) |
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Census Address(es) |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS |
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CENSUS ADDRESS 1 |
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XXXXX |
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CENSUS ADDRESS 2 |
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2. Is there a housing unit at CENSUS ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 2 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
__________________________________________________________________ Skip to Question 7
3. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS 2
Yes
No In what block number is CENSUS ADDRESS 2? (B1)
4. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)
housing unit as CENSUS ADDRESS 2?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
CCM-Census Match/Duplicate Census Address (M/DE)
CCM Address(es) |
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Census Address(es) |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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XXXXX |
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CCM ADDRESS |
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CENSUS ADDRESS 1 |
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XXXXX |
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CENSUS ADDRESS 2 |
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5. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address (G2)
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes Enter Census ID:
No
6. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
7. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
8. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es) |
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Census Address(es) |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
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XXXXX |
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XXXXX |
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CCM ADDRESS 1 |
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CENSUS ADDRESS |
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XXXXX |
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CCM ADDRESS 2 |
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XXXXX |
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CCM ADDRESS 3 |
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FIRST CCM DUPLICATE RECORD
1. Do the following addresses refer to the same housing unit? (C)
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes What is the correct address? (C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 6
Other _________________________________________________ ® Skip to Question 6
No
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es) |
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Census Address(es) |
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Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
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XXXXX |
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XXXXX |
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CCM ADDRESS 1 |
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CENSUS ADDRESS |
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XXXXX |
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CCM ADDRESS 2 |
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XXXXX |
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CCM ADDRESS 3 |
|
|||||||||||
|
||||||||||||
2. Is there a housing unit at CCM ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 2 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 13
3. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 2
Yes
No In what block number is CCM ADDRESS 2? (B1)
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es) |
|
Census Address(es) |
||||||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|||
XXXXX |
|
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XXXXX |
|
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|||
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
||||||||||
XXXXX |
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CCM ADDRESS 2 |
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XXXXX |
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CCM ADDRESS 3 |
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|
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4. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?
Yes Enter Census ID:
No
5. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes Enter CCM MSN and WMSN
No
6. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
SECOND CCM DUPLICATE RECORD
7. Do the following address refer to the same housing unit? (C)
CCM Adress: CCM ADDRESS 1
CCM Address: CCM ADDRESS 3
Yes What is the correct address? (C1)
CCM ADDRESS 1
CCM ADDRESS 3
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 12
Other _________________________________________________ ® Skip to Question 12
No
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es) |
|
Census Address(es) |
||||||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|||
XXXXX |
|
|
|
|
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XXXXX |
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|||
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
||||||||||
XXXXX |
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CCM ADDRESS 2 |
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XXXXX |
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CCM ADDRESS 3 |
|
|||||||||||
|
||||||||||||
8. Is there a housing unit at CCM ADDRESS 3? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 3 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
_________________________________________________________________ Skip to Question 13
9. Is CCM ADDRESS 3 located in block XXXXX? (B)
Yes
No In what block number is CCM ADDRESS 3? (B1)
10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 3?
Yes Enter Census ID:
No
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es) |
|
Census Address(es) |
||||||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|||
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
|||
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
||||||||||
XXXXX |
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CCM ADDRESS 2 |
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XXXXX |
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CCM ADDRESS 3 |
|
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|
||||||||||||
11. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 3?
Yes Enter CCM MSN and WMSN
No
12. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
13. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
14. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes: ______________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
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XXXXX |
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CENSUS ADDRESS 2 |
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XXXXX |
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CENSUS ADDRESS 3 |
||||||||
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FIRST CENSUS DUPLICATE RECORD
1. Do the following addresses refer to the same housing unit? (C)
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes What is the correct address? (C1)
CNESUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 6
Other _________________________________________________ ® Skip to Question 6
No
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
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XXXXX |
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CENSUS ADDRESS 2 |
|||||||
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|||||||||
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XXXXX |
|
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CENSUS ADDRESS 3 |
||||||||
|
|||||||||
2. Is there a housing unit at CENSUS ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 2 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 13
3. Is this address located in block XXXXX? (B)
CENSUS Address: CENSUS ADDRESS 2
Yes
No In what block number is CENSUS ADDRESS 2? (B1)
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
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XXXXX |
|
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CENSUS ADDRESS 2 |
|||||||
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XXXXX |
|
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CENSUS ADDRESS 3 |
||||||||
|
|||||||||
4. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)
same housing unit as CENSUS ADDRESS 2?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
5. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address (G2)
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes Enter Census ID:
No
6. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
SECOND CENSUS DUPLICATE RECORD
7. Do the following addresses refer to the same housing unit? (C)
Census address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 3
Yes What is the correct address? (C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 3
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 12
Other _________________________________________________ ® Skip to Question 12
No
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE )
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
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|
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XXXXX |
|
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CENSUS ADDRESS 2 |
|||||||
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|||||||||
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XXXXX |
|
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|
CENSUS ADDRESS 3 |
||||||||
|
|||||||||
8. Is there a housing unit at CENSUS ADDRESS 3? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 3 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 13
9. Is CENSUS ADDRESS 3 located in block XXXXX? (B)
Yes
No In what block number is CENSUS ADDRESS 3? (B1)
10. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)
same housing unit as CENSUS ADDRESS 3?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE )
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
XXXXX |
|
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|
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|
CENSUS ADDRESS 2 |
|||||||
|
|||||||||
|
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XXXXX |
|
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|
|
CENSUS ADDRESS 3 |
||||||||
|
|||||||||
11. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address (G2)
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 3?
Yes Enter Census ID:
No
12. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
13. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
14. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
CCM Nonmatched and Duplicate Addresses (NI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
CCM DUPLICATE RECORD
1. Do the following addresses refer to the same housing unit? (C)
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes What is the correct address? (C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 6
Other _________________________________________________ ® Skip to Question 6
No
CCM Nonmatched and Duplicate Addresses (NI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
2. Is there a housing unit at CCM ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 2 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 12
3. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 2
Yes
No In what block number is CCM ADDRESS 2? (B1)
4. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)
housing unit as CCM ADDRESS 2?
Yes Enter Census ID:
No
CCM Nonmatched and Duplicate Addresses (NI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
5. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes Enter CCM MSN and WMSN
No
6. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
CCM Nonmatched and Duplicate Addresses (NI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
CCM Nonmatch
7. Is there a housing unit at CCM ADDRESS 1? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 1. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
____________________________________________________________________________________
_________________________________________________________________ Skip to Question 12
8. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 1
Yes
No In what block number is CCM ADDRESS 1? (B1)
9. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)
housing unit as CCM ADDRESS 1?
Yes Enter Census ID:
No
CCM Nonmatched and Duplicate Addresses (NI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
10. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 1?
Yes Enter CCM MSN and WMSN
No
11. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
12. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
13. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Census Nonmatched and Duplicate Addresses (NE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 2 |
|||||||
CENSUS DUPLICATE RECORD
1. Do the following addresses refer to the same housing unit? (C)
Census address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes What is the correct address? (C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 6
Other _________________________________________________ ® Skip to Question 6
No
Census Nonmatched and Duplicate Addresses (NE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 2 |
|||||||
2. Is there a housing unit at CENSUS ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 2 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________ Skip to Question 12
3. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS 2
Yes
No In what block number is CENSUS ADDRESS 2? (B1)
4. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)
same housing unit as CENSUS ADDRESS 2?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
Census Nonmatched and Duplicate Addresses (NE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 2 |
|||||||
5. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address (G2)
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes Enter Census ID:
No
6. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
Census Nonmatched and Duplicate Addresses (NE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 2 |
|||||||
CENSUS Nonmatch
7. Is there a housing unit at CENSUS ADDRESS 1? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 1. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 12
8. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS 1
Yes
No In what block number is CENSUS ADDRESS 1? (B1)
9. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)
same housing unit as CENSUS ADDRESS 1?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
Census Nonmatched and Duplicate Addresses (NE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 2 |
|||||||
10. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address (G2)
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 1?
Yes Enter Census ID:
No
11. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
12. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
13. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Unit Status Update or Surrounding Block Match (M*)
CCM Address |
|
Census Address |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS |
|||||||
1. Is there a housing unit at CCM ADDRESS? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
__________________________________________________________________________________
________________________________________________________________ Skip to Question 4
2. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS
Yes
No In what block number is CCM ADDRESS? (B1)
3. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
Unit Status Update or Surrounding Block Match (M*)
CCM Address |
|
Census Address |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS |
|||||||
4. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
5. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Unit Status Update or Surrounding Block Match/Duplicate CCM Address (M*/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
1. Is there a housing unit at CCM ADDRESS 1? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 1. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 10
2. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 1
Yes
No In what block number is CCM ADDRESS 1? (B1)
3. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
Unit Status Update or Surrounding Block Match/Duplicate CCM Address (M*/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
CCM DUPLICATE RECORD
4. Do the following addresses refer to the same housing unit? (C)
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes What is the correct address? (C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 10
Other _________________________________________________ ® Skip to Question 10
No
5. Is there a housing unit at CCM ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 2 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 10
Unit Status Update or Surrounding Block Match/Duplicate CCM Address (M*/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
6. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 2
Yes
No In what block number is CCM ADDRESS 2? (B1)
7. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?
Yes Enter Census ID:
No
8. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2) top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes Enter CCM MSN and WMSN
No
9. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
10. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
11. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Unit Status Update or Surrounding Block Match/Duplicate Census Address (M*/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 2 |
|||||||
1. Is there a housing unit at CCM ADDRESS? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 10
2. Is this address located in block XXXXX? (B)
Census Address: CCM ADDRESS
Yes
No In what block number is CCM ADDRESS? (B1)
3. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
Unit Status Update or Surrounding Block Match/Duplicate Census Address (M*/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 2 |
|||||||
CENSUS DUPLICATE RECORD
4. Do the following addresses refer to the same housing unit? (C)
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes What is the correct address? (C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 10
Other _________________________________________________ ® Skip to Question 10
No
5. Is there a housing unit at CENSUS ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 2 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
__________________________________________________________________________________
_______________________________________________ Skip to Question 10
Unit Status Update or Surrounding Block Match/Duplicate Census Address (M*/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 2 |
|||||||
6. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS 2
Yes
No In what block number is CENSUS ADDRESS 2? (B1)
7. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)
same housing unit as CENSUS ADDRESS 2?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
8. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address (G2)
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes Enter Census ID:
No
9. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
10. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
11. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses (M*/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
1. Is there a housing unit at CCM ADDRESS 1? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 1 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
__________________________________________________________________________________
________________________________________________________________ Skip to Question 16
2. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 1
Yes
No In what block number is CCM ADDRESS 1? (B1)
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses (M*/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
3. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
FIRST CCM DUPLICATE RECORD
4. Do the following addresses refer to the same housing unit? (C)
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes What is the correct address? (C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 10
Other _________________________________________________ ® Skip to Question 10
No
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses (M*/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
5. Is there a housing unit at CCM ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 2 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 16
6. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 2
Yes
No In what block number is CCM ADDRESS 2? (B1)
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses (M*/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
7. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?
Yes Enter Census ID:
No
8. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes Enter CCM MSN and WMSN
No
9. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
SECOND CCM DUPLICATE RECORD
10. Do the following addresses refer to the same housing unit? (C)
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 3
Yes What is the correct address? (C1)
CCMA ADDRESS 1
CCM ADDRESS 3
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 16
Other _________________________________________________ ® Skip to Question 16
No
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses (M*/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
|||||||
XXXXX |
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CCM ADDRESS 2 |
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XXXXX |
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CCM ADDRESS 3 |
|
||||||||
|
|||||||||
11. Is there a housing unit at CCM ADDRESS 3? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 3 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
_________________________________________________________________ Skip to Question 16
12. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 3
Yes
No In what block number is CCM ADDRESS 3? (B1)
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses (M*/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS 1 |
|
CENSUS ADDRESS |
|||||||
XXXXX |
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CCM ADDRESS 2 |
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XXXXX |
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CCM ADDRESS 3 |
|
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|||||||||
13. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 3?
Yes Enter Census ID:
No
14. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box (F2)
at the top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?
Yes Enter CCM MSN and WMSN
No
15. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
16. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
17. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
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XXXXX |
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CENSUS ADDRESS 2 |
|||||||
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XXXXX |
|
|
|
|
CENSUS ADDRESS 3 |
||||||||
|
|||||||||
1. Is there a housing unit at CCM ADDRESS? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
________________________________________________________________ Skip to Question 16
2. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS
Yes
No In what block number is CCM ADDRESS? (B1)
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
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XXXXX |
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CENSUS ADDRESS 2 |
|||||||
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|||||||||
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XXXXX |
|
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CENSUS ADDRESS 3 |
||||||||
|
|||||||||
3. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
FIRST CENSUS DUPLICATE RECORD
4. Do the following addresses refer to the same housing unit? (C)
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes What is the correct address? (C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 10
Other _________________________________________________ ® Skip to Question 10
No
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
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XXXXX |
|
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|
CENSUS ADDRESS 2 |
|||||||
|
|||||||||
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XXXXX |
|
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|
CENSUS ADDRESS 3 |
||||||||
|
|||||||||
5. Is there a housing unit at CENSUS ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 2 (A1)
Under construction or future construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
__________________________________________________________________________________
_______________________________________________________________ Skip to Question 16
6. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS 2
Yes
No In what block number is CENSUS ADDRESS 2? (B1)
7. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)
same housing unit as CENSUS ADDRESS 2?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
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|
XXXXX |
|
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CENSUS ADDRESS 2 |
|||||||
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|||||||||
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XXXXX |
|
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|
CENSUS ADDRESS 3 |
||||||||
|
|||||||||
8. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address (G2)
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes Enter Census ID:
No
9. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
SECOND CENSUS DUPLICATE RECORD
10. Do the following addresses refer to the same housing unit? (C)
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 3
Yes What is the correct address? (C1)
CCM ADDRESS 1
CCM ADDRESS 3
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 16
Other _________________________________________________ ® Skip to Question 16
No
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
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|
|
XXXXX |
|
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|
CENSUS ADDRESS 2 |
|||||||
|
|||||||||
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XXXXX |
|
|
|
|
CENSUS ADDRESS 3 |
||||||||
|
|||||||||
11. Is there a housing unit at CENSUS ADDRESS 3? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 3 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_____________________________________________________________________________ Skip to Question 16
12. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS 3
Yes
No In what block number is CENSUS ADDRESS 3? (B1)
13. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)
housing unit as CENSUS ADDRESS 3?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
XXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
|||||||
|
|
|
|
|
|
XXXXX |
|
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|
CENSUS ADDRESS 2 |
|||||||
|
|||||||||
|
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|
|
XXXXX |
|
|
|
|
CENSUS ADDRESS 3 |
||||||||
|
|||||||||
14. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address (G2) box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 3?
Yes Enter Census ID:
No
15. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
16. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
17. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CCM Nonmatched/Two Duplicate CCM Adresses (NI/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
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|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
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|
|
|
|
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|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
FIRST CCM DUPLICATE RECORD
1. Do the following addresses refer to the same housing unit? (C)
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes What is the correct address? (C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 6
Other _________________________________________________ ® Skip to Question 6
No
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
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|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
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|
|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
2. Is there a housing unit at CCM ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 2. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
__________________________________________________________________________________
_______________________________________________________________ Skip to Question 18
3. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 2
Yes
No In what block number is CCM ADDRESS 2? (B1)
4. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?
Yes Enter Census ID:
No
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
|
|
|
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|
|
|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
5. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes Enter CCM MSN and WMSN
No
6. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
SECOND CCM DUPLICATE RECORD
7. Do the following addresses refer to the same housing unit? (C)
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 3
Yes What is the correct address? (C1)
CCM ADDRESS 1
CCM ADDRESS 3
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 13
Other _________________________________________________ ® Skip to Question 13
No
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
|
|
|
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|
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|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
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|
|
|
|
|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
8. Is there a housing unit at CCM ADDRESS 3? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 3. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
___________________________________________________________________________________
_________________________________________________________________ Skip to Question 18
9. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 3
Yes
No In what block number is CCM ADDRESS 3? (B1)
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 3?
Yes Enter Census ID:
No
11. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 3?
Yes Enter CCM MSN and WMSN
No
12. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 1 |
|
|
|||||||
XXXXX |
|
|
|
|
|
|
|
|
|
CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXX |
|
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|
|
|
|
|
|
|
CCM ADDRESS 3 |
|
||||||||
|
|||||||||
CCM NONMATCH RECORD
13. Is there a housing unit at CCM ADDRESS 1? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CCM ADDRESS 1 (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
__________________________________________________________________________________
_______________________________________________ Skip to Question 18
14. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS 1
Yes
No In what block number is CCM ADDRESS 1? (B1)
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es) |
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Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
XXXXX |
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CCM ADDRESS 1 |
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XXXXX |
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CCM ADDRESS 2 |
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XXXXX |
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CCM ADDRESS 3 |
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15. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 1?
Yes Enter Census ID:
No
16. Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 1?
Yes Enter CCM MSN and WMSN
No
17. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
18. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
19. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
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XXXXX |
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CENSUS ADDRESS 1 |
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XXXXX |
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CENSUS ADDRESS 2 |
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XXXXX |
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CENSUS ADDRESS 3 |
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FIRST CENSUS DUPLICATE RECORD
1. Do the following addresses refer to the same housing unit? (C)
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes What is the correct address? (C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 6
Other _________________________________________________ ® Skip to Question 6
No
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
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Block |
Census ID |
MSN |
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XXXXX |
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CENSUS ADDRESS 1 |
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XXXXX |
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CENSUS ADDRESS 2 |
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XXXXX |
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CENSUS ADDRESS 3 |
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2. Is there a housing unit at CENSUS ADDRESS 2? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 2. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
__________________________________________________________________________________
_______________________________________________________________ Skip to Question 18
3. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS 2
Yes
No In what block number is CENSUS ADDRESS 2? (B1)
4. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)
housing unit as CENSUS ADDRESS 2?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
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XXXXX |
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CENSUS ADDRESS 1 |
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XXXXX |
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CENSUS ADDRESS 2 |
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XXXXX |
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CENSUS ADDRESS 3 |
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5. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address box (G2)
at the top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes Enter Census ID:
No
6. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
SECOND CENSUS DUPLICATE RECORD
7. Do the following addresses refer to the same housing unit? (C)
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 3
Yes What is the correct address? (C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 3
Other _________________________________________________
What is the correct block? (C2)
XXXXX ® Skip to Question 13
Other _________________________________________________ ® Skip to Question 13
No
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
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XXXXX |
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CENSUS ADDRESS 1 |
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XXXXX |
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CENSUS ADDRESS 2 |
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XXXXX |
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CENSUS ADDRESS 3 |
||||||||
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8. Is there a housing unit at CENSUS ADDRESS 3? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 3. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
__________________________________________________________________________________
_______________________________________________________________ Skip to Question 18
9. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS 3
Yes
No In what block number is CENSUS ADDRESS 3? (B1)
10. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)
housing unit as CENSUS ADDRESS 3?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
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XXXXX |
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CENSUS ADDRESS 1 |
|||||||
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XXXXX |
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CENSUS ADDRESS 2 |
|||||||
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XXXXX |
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CENSUS ADDRESS 3 |
||||||||
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11. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address box (G2)
at the top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 3?
Yes Enter Census ID:
No
12. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
|
|
|
|
|
|
XXXXX |
|
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CENSUS ADDRESS 1 |
|||||||
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XXXXX |
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CENSUS ADDRESS 2 |
|||||||
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XXXXX |
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CENSUS ADDRESS 3 |
||||||||
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|||||||||
CENSUS NONMATCH RECORD
13. Is there a housing unit at CENSUS ADDRESS 1? (A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________ No Please describe the status of CENSUS ADDRESS 1. (A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage of non-household goods
Other Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
__________________________________________________________________________________
_______________________________________________________________ Skip to Question 18
14. Is this address located in block XXXXX? (B)
Census Address: CENSUS ADDRESS 1
Yes
No In what block number is CENSUS ADDRESS 1? (B1)
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es) |
|
Census Address(es) |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
|
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XXXXX |
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CENSUS ADDRESS 1 |
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XXXXX |
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CENSUS ADDRESS 2 |
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XXXXX |
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CENSUS ADDRESS 3 |
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15. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D) housing unit as CENSUS ADDRESS 1?
Yes Enter CCM MSN and WMSN
No Add new map spot to the CCM Block Cluster Map, then enter the map spot number here:
16. Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address box (G2)
at the top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 1?
Yes Enter Census ID:
No
17. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
18. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
19. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Group Quarters (GQ)
CCM Address |
|
Census Address |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
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|
|
XXXXX |
|
|
CCM ADDRESS |
|
<Print Census Address if Matched to the CCM Address> |
|||||||
1. Hello my name is (your name). I’m from the U.S. Census Bureau (show your identification badge). I’d like to speak (H)
with someone who can answer questions about the type of place this is. Would that be you, or should I speak
with someone else?
(Continue, or if referred to another respondent, re-read paragraph above).
We are checking addresses in this area as part of the 2008 Census Dress Rehearsal. Here is some information
about what we are doing. The questions should take about 3 minutes. (Hand the person the Privacy Act Notice
and allow time for the person to read it.)
READ IF NECESSARY: I won’t need to interview residents here; I just want to ask some very basic questions about
the type of place this is.
2. Next I’m going to show you a list [HAND FLASHCARD TO RESPONDENT]. Which of these best describes (I)
this place?
A: Correctional facility Skip to Question 9
B: Dormitory, residence hall, fraternity or sorority house for students at a college, university, or
seminary Skip to Question 9
C: Group home or residential treatment center Skip to Question 9
D: Health care facility or nursing home Skip to Question 9
E: Independent or assisted living facility WITH 24-hour skilled nursing unit or facility
(ask for brochure) Skip to Question 4
F: Independent or assisted living facility WITHOUT 24-hour skilled nursing unit or facility
(ask for brochure) Skip to Question 4
G: Recreational Vehicle (RV) park, campground, marina or racetrack Skip to Question 5
H: Religious group quarters Skip to Question 9
I: Residential school for people with disabilities Skip to Question 9
J: Shelter Skip to Question 9
K: Workers’ group living quarters or Job Corps center Skip to Question 9
L: None of the above Skip to Question 3
3. Is this a private residence? (J)
Yes Skip to Question 5
No Skip to Question 4
4. Please describe this place: _________________________________________________________________________ (K)
_________________________________________________________________________
5. Is this address located in block XXXXX? (B)
CCM Address: CCM ADDRESS
Yes
No In what block number is CCM ADDRESS? (B1)
Group Quarters (GQ)
CCM Address |
|
Census Address |
|||||||
Block |
MSN |
WMSN |
TOA |
Unit Status |
# Units |
|
Block |
Census ID |
MSN |
XXXXX |
|
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|
XXXXX |
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|
CCM ADDRESS |
|
<Print Census Address if Matched to the CCM Address> |
|||||||
6. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?
Yes Enter Census ID:
No
7. Look at the CCM column of the Housing Unit Reference List. Notice that the address in the CCM address box at the (F1)
top of this form is already listed in that column. Aside from that address, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS?
Yes Enter CCM MSN and WMSN
No
8. How many housing units are at this basic street address? (L)
One
More than one How many? ____________ (L1)
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
No housing units at this basic street address
9. [Go to next question./Fill question or note from analyst beginning with: Special question:] (M)
{Programming Note: If a Possible Match, Insert Question C after any analyst notes.}
Special question: <Fill analyst notes>
Do the following addresses refer to the same housing unit? (C)
CCM Address: <Appropriate Address>
Census Address: <Possible Match Address>
Yes
No
10. Main source of information you used to fill out questions: (N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
FORM DX-1380 (04/09/2007) U.S. DEPARTMENT OF COMMERCE
OMB No. XXXX-XXXX: Economics and Statistics Administration
Approval Expires XX/XX/20XX U.S. CENSUS BUREAU
Census Coverage Measurement (CCM)
Initial Housing Unit Followup (IHUFU) Quality Control (QC) Form
2008 Census Dress Rehearsal
Page XX of XX
Section A: Identification |
||||||||||||||||||||||||||||
1. Cluster No. |
XXXXXXXX |
2. LCO Name |
XXXXXXXXXXXXXXXXXXXX |
3. LCO Code |
XXXX |
|||||||||||||||||||||||
Section B: Assignment Information |
||||||||||||||||||||||||||||
Position (a)
|
Name (b) |
Applicant ID (c) |
Dates |
|||||||||||||||||||||||||
Assigned (d) |
Completed (e) |
|||||||||||||||||||||||||||
Month |
Day |
Month |
Day |
|||||||||||||||||||||||||
1. QC Crew Leader |
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| | | |
| | | |
| | | |
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2. QC Checker |
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| | | |
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3. QC Checker |
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| | | |
||||||||||||||||||||||
Section C: QC Check |
||||||||||||||||||||||||||||
Followup Cases Selected for QC Check |
QC Result |
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Block(a) |
CCM |
Census |
Followup Code(f) |
Case Correct(No Critical Errors) (g) |
Case Incorrect(One or More Critical Error(s)) (h) |
|||||||||||||||||||||||
MSN(b) |
WMSN(c) |
Census ID(d) |
MSN(e) |
|||||||||||||||||||||||||
XXXXX |
XXXXX |
XXXX |
XXXXXXXXXXXXXX |
XXXXX |
XXXXXXXX |
|||||||||||||||||||||||
XXXXX |
XXXXX |
XXXX |
XXXXXXXXXXXXXX |
XXXXX |
XXXXXXXX |
|||||||||||||||||||||||
XXXXX |
XXXXX |
XXXX |
XXXXXXXXXXXXXX |
XXXXX |
XXXXXXXX |
|||||||||||||||||||||||
XXXXX |
XXXXX |
XXXX |
XXXXXXXXXXXXXX |
XXXXX |
XXXXXXXX |
|||||||||||||||||||||||
(Note: Listing of sample continues as needed. It might require multiple pages) |
||||||||||||||||||||||||||||
1. Total Number of Cases Selected for QC Check XX |
2. Total Correct |
3. Total Incorrect |
||||||||||||||||||||||||||
4. QC Check Outcome (Mark (X) one) Pass Fail - Rectify |
||||||||||||||||||||||||||||
5. Notes
|
||||||||||||||||||||||||||||
Section D: Rectification |
||||||||||||||||||||||||||||
Block Number (a) |
Number of Followup Cases (b) |
Number of Incorrect Cases (Critical Error(s)) (c) |
||||||||||||||||||||||||||
XXXXX |
XXX |
|
||||||||||||||||||||||||||
XXXXX |
XXX |
|
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XXXXX |
XXX |
|
||||||||||||||||||||||||||
XXXXX |
XXX |
|
||||||||||||||||||||||||||
Total |
XXX |
|
||||||||||||||||||||||||||
Section E: Acceptance Table |
||||||||||||||||||||||||||||
Sample Size |
1 - 6 |
12 |
20 |
28 |
37 |
46 |
56 |
|||||||||||||||||||||
Allowable Errors |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
|||||||||||||||||||||
CENSUS CONFIDENTIAL: RESTRICTED DATA FOR OFFICIAL USE ONLY. Information contained in this report is for use by the Census Bureau and is confidential by law (Title 13, U.S.C.). It may be seen only by sworn Census employees and may be used only for statistical purposes.
| File Type | application/msword |
| File Title | NI Question Box |
| Author | Tony Rosenberger |
| Last Modified By | parso306 |
| File Modified | 2008-09-05 |
| File Created | 2008-09-05 |
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